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64 for 32

Computers for Resident Physicians

On June 25, 2014 I’m going to heft a set of golf clubs and hoof 64 holes of golf in one day in an attempt to raise $64,000 for 32 brilliant resident physicians in the University of Missouri Kansas City School of Medicine’s Community and Family Medicine Residency program.  Why?

The answer involves a 30 year journey from academic medicine away and back to academic medicine.  This journey involving stints in the C-Suite, departmental management, software development, consulting, primary care practice and retail medicine.  Many lessons were learned during that journey and I now have enough gray hairs to show for it and earned the responsibility of teaching again.

See One, Do One, Teach One

More than other disciplines medicine is driven by self learning in which after graduating from medical school the “see one, do one, teach one” approach becomes the most common method of learning.  The best learning is hands on after observing and then internalizing the experience by teaching a colleague but most importantly, the patient.

The exam room, like it or not, is a primary care physician’s surgical suite.  No surgical program would ever consider graduating surgeons who have never watched an attending do a procedure or use a critical surgical implement or device in an actual surgery.  Yet it appears that we’re very comfortable with graduating thousands of physicians without ever watching an attending physician do one key skill that will dominate their lives in the foreseeable future: Using a computer with a patient in the exam room.

Medical knowledge has exploded and we all recognize that it’s impossible for individual physicians, no matter how specialized they are, to keep up with the knowledge needed for good patient care.  Primary Care Physicians are responsible for more information than any specialists are since their services cover everything from the cradle to the grave.  The computer and access to the world is the primary care physician’s most important tool in delivering services and education to their patients.  Using that tool skillfully to meet the needs of the patient with the patient during the many visits is one of the core skill sets faculty need to be able to demonstrate and teach our new resident physicians and medical students.

Jail Cell Exam Rooms

Many academic medical centers are located in inner city environments and are obligated to see a large indigent population.  While this is laudable and serves a great purpose for clinical education it puts extreme pressure on academic institutions to adequately fund technology for their residents and faculty.  The tendency is to scarce capital into surgical, cardiac, cancer and other high-profile specialty and subspecialty areas that can be leveraged for more fund raising or used in highly reimbursed procedures.

Can't do 2 things at once

Can’t do 2 things at once

The result is the thousands of exam rooms in these centers are neglected.  For example, our exam room computers are over 5 years old, still use antiquated and officially unsupported Windows XP, have small 17″ screens and are plastered on the walls in places that force the physician to turn their back on the patient.  These systems are so full of security holes most of these them are locked down so they can only access the Electronic Medical Record.  They are incapable of being used to adequately answer the physician and patient’s questions and certainly can’t be used to access the vast amount of free web-based educational material.

As currently configured these devices are incapable of augmenting, participating and contributing effectively to the exam room visit.

Those few residents who have access to recent mobile hardware have an advantage in that they can use these devices to better access not only the Medical Record but sit next to the patient and use them to share with the patient the rich educational material to which they have access. Unfortunately the majority of residents do not have the financial resources for this.  Why don’t all resident physicians have the latest devices?  Most carry a very heavy undergraduate and graduate student loan burden (well into 6 digits) and are trying to exist on salaries that barely let them survive let alone make significant technology purchases.

They are heading into a world that is dependent on the latest technology yet have not “seen one,” let alone “do one.”  They have been learning in hopeless antiquated and dysfunctional jail cells.  When they graduate and enter clinics and partnerships that have more resources they have a hard time learning how to use this technology effectively while they are building their practices under the pressures of productivity.  Unfortunately most are going to head into clinics filled with exam rooms just like those they had in their training programs.

There are those who are using technology to transform the exam rooms into highly functioning facilities that manufacture magic moments for their patients.  The irony is these are rarely, if ever, found in academic medical centers.

The Computer in the Room

Technology can help transform exam rooms from jail cells to magic rooms.  We practice in a digital world and one of the computer’s functions in the exam room is to facilitate recording details of that visit for medical, legal and financial purposes.  But unlike many other transaction interactions, the exam room computer must augment the physician/patient interaction and become the 3rd person in the room.  Practices that are doing this effectively realize the patient-physician-computer triangle is key to effective communications.   Examples of these can be seen in the photos below where the computer is being used to not only gather information but educate the patient at the same time.

Accessing and sharing information with patient

Accessing and sharing information with patient

Doing Multiple Things Seamlessly

Doing Multiple Things Seamlessly

I’m fond of saying it’s one thing to learn to play a piano, another to play a recital but a whole different skill to play a piano in a piano bar.  Unlike a recital where the piano is the object the piano must accompany the conversation between the pianist and the patron in a piano bar.  This is a hard skill to learn and this whole project is designed to help our residents learn to use their computers to accompany the fundamental patient/physician conversation at the same time it’s doing the transactional functions.

While I’d like to completely replace all of the computers in all of the academic exam rooms I’m a realist to know very few institutions have the resources to do this.  However, we can accomplish much of the same thing by arming every one of our residents with state-of-the-art computers and then either using the existing monitors in the room or adding inexpensive monitors to which these devices can connect wirelessly to when needed.  These computers will not be locked down and the resident will be able to use them to access the needed resources such as Zygote Body, Up-To-Date, Visual Dx or any other resource needed at the point of care.

You Can Help

By logging into https://ecommerce.umkc.edu/giving and scrolling down to the bottom of the Donation web sitepage, select Other and then enter “Nicholas Fund – to be used for Family Practice resident technology”.   Then enter the amount you are donating to support the residents and my slogging out on June 25th.  You will enable us to provide these brilliant residents with the latest technology possible.  In the process you will be helping not only them, their patients but also sending a message that Primary Care is important. Please help me raise $64,000 for the 42 residents on June 25th, 2014.

Comments Welcomed

A Short List of Technologies Changing My Practice

Was asked for a short list of what technologies have made a difference in my practice over the last year and I rapidly jotted down the following:

Large screen devices

  • Our clinic started with small notebook computers primarily designed for the physician and nurses to carry from room to room.  Severaly years ago it became apparent that we often needed to share what was on those screens with patients (primarily diagnostic imaging and lab results).  The hand-held devices didn’t cut it.
  • We moved to 19″ regular monitors and after some experimentation ditched the notebooks and took the minimal added time to log into inexpensive autologon desktops and increased the size of the monitors to 21″ swivel devices
  • Now have gone to 24″ HP All-In-One touchscreen devices for nurses and patient rooms because we discovered productivity is proportional to screen real estate and the added dimensions of the touch screen enabled us to include patient input into the documentation process in the exam room

Photos and videos

  • Having a current patient photo on every page view of the chart (usually in banner bar) reduces errors of performing actions on the wrong patient, reduces the need to dig for information (pictures jar our memories in ways names cannot)
  • Having pictures of rashes, wounds, deformities provides more information for downstream readers than any amount of words
  • Including videos of tremors, gaits, movements improves diagnoses
  • Provides excellent teaching tool
  • Has dramatically decreased the amount of descriptive text and time to completion of notes without sacrificing information
  • Enables visit-to-visit comparison that is just not possible with text

Electronic Messaging, especially with patients

  • Asynchronous messaging reduces interruptions for both the clinician and the patient and is more efficient than voice.  Patient’s complaints are in their own words eliminating the need for redundant recording of the interaction
  • Improves communication without adding cost and dramatically reduces time spent on the phone. Secure messaging enables electronic transfer of patient information to outside physicians in need of that information when normal record transfer mechanisms are not available

ePrescribe

  • Especially the External History has the potential to change the conversation (discovers those who have not filled prescriptions as well as those that are doctor shopping)
  • Also having access to the medications covered by specific plans and the co-pay for those medications is what I call REAL DECISION SUPPORT … now if only we could get the same push for covered services

Point of Care use

  • Improves timeliness and also accuracy of the interaction
  • Increases the perception of time spent with the patient
  • Increases confidence and satisfaction

Patient Access to chart, especially visit notes

  • Improves the accuracy, integrity and timeliness of the notes
  • Try to review and write the note (even though I’m using 100% template driven documentation in the clinic) with the patient as the next reader and editor of the note.  Takes a little more time but forces me to be judicious and accurate in my documentation which I’m convinced improves patient care

Interfaces and connections … Health Information Exchanges

  • The power of an EHR increases logarithmically with the number of systems to which it is connected
  • HIE connections have the potential to increase productivity (see new patients in the same time as established patients)  and why they are not catching on is beyond my comprehension as they enable a clinic to schedule and see new patients in the same time slots as established patients by dramatically reducing the amount of de novo data entry required to make medical decisions

There are many more technologies and infrastructure changes that are positively impacting health care but these are the ones that came to mind as fast as I could type them.

Comments?